Employment Application

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Please fill out to this form to best of your ability. You can upload your resume too.

Name*

Gender*

Male

Female

Date of Birth*

Email*

Main Phone*

Other Phone

Please list any other names you have been employed under*

Address*

Are you eligible to work in the United States?

Are you 18 years old or older?

Position applied for*

When can you start*

Salary Desired Per Month

$

Dollars

Cents

Have you been employed by our organization in the past

If yes, please provide dates of employment and the position held.

Date of employment

Position

Do you have any relative employed by our organization

If yes, please indicate name and relationship.

Name

Relationship

How did you learn about about our organization*

BACKGROUND INFORMATION

Have you ever been convicted of a felony or a 1st degree misdemeanor

If “Yes”, please explain

Have you ever pled nolo contendere, guilty had the adjudication withheld or are you now under charges for a crime which is a felony or a 1st degree misdemeanor?

If “Yes”, please explain

HIGH SCHOOL

High School Name

High School Address

High School: Dates Attended

High School: Degree Major

UNDERGRADUATE SCHOOL

Undergraduate School: Name

Undergraduate School: Address

Undergraduate School: Dates Attended

Undergraduate School: Degree Major

GRADUATE SCHOOL

Graduate School: Name

Graduate School: Address

Graduate School: Dates Attended

Graduate School: Degree Major

TECHNICAL KNOWLEDGE

Technical/Trade School: Name

Technical/Trade School: Address

Technical/Trade School: Dates Attended

Technical/Trade School: Degree Major

SPECIAL SKILLS & LICENSES

Special Training/Special Skills

Certifications / Licenses

EMPLOYMENT HISTORY

LIST BELOW LAST FOUR (4) EMPLOYERS, STARTING WITH THE MOST RECENT ONE FIRST.

EMPLOYER 1

Employer 1: Name*

Employer 1: Job Title

Employer 1: Address*

Employer 1: Dates Employed:*

Employer 1: Salary Starting*

$

Dollars

Cents

Employer 1: Salary Final*

$

Dollars

Cents

Employer 1: Name/Title of the Supervisor*

Employer 1: May we contact your supervisor?*

Employer 1: Description of Work*

Employer 1: Reason for Leaving*

EMPLOYER 2

Employer 2: Name

Employer 2: Job Title

Employer 2: Address

Employer 2: Dates Employed:

Employer 2: Salary Starting

$

Dollars

Cents

Employer 2: Name/Title of the Supervisor

Employer 2: May we contact your supervisor?

Employer 2: Description of Work

Employer 2: Reason for Leaving

EMPLOYER 3

Employer 3: Name

Employer 3: Job Title

Employer 3: Address

Employer 3: Dates Employed:

Employer 3: Salary Starting

$

Dollars

Cents

Employer 3: Name/Title of the Supervisor

Employer 3: May we contact your supervisor?

Employer 3: Description of Work

Employer 3: Reason for Leaving

EMPLOYER 4

Employer 4: Name

Employer 4: Job Title

Employer 4: Address

Employer 4: Dates Employed:

Employer 4: Salary Starting

$

Dollars

Cents

Employer 4: Name/Title of the Supervisor

Employer 4: May we contact your supervisor?

Employer 4: Description of Work

Employer 4: Reason for Leaving

REFERENCES

LIST INFORMATION FOR (4) PERSONS YOU ARE NOT RELATED TO AND YOU HAVE KNOWN A MINIMUM OF ONE YEAR. OF THOSE FOUR (4) REFERENCE S, TWO (2) OF THE REFERENCES MUST BE PERSONS YOU HAVE WORKED WITH IN THE PAST.

REFERENCES 1

Reference 1: Name*

Reference 1: Title*

Reference 1: Phone*

Reference 1: Years of Acquainted/Relationship*

Refernce 1: Email

Refernce 1: Address*

REFERENCES 2

Reference 2: Name*

Reference 2: Title

Reference 2: Phone*

Reference 2: Years of Acquainted/Relationship*

Refernce 2: Email

Refernce 2: Address*

REFERENCES 3

Reference 3: Name*

Reference 3: Title

Reference 3: Phone*

Reference 3: Years of Acquainted/Relationship*

Refernce 3: Email

Refernce 3: Address*

SERVICE RECORD

Branch of Service

Discharge Date

Rank

Have you been convicted of a misdemeanor or felony within the last 5 years?*

If Yes, please explain. (Will not necessarily exclude you from consideration)

AUTHORIZATION

“I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL” - (TYPE FULL NAME)*

“I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION” - (TYPE FULL NAME)*

“I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY O ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE NY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE.” - (TYPE FULL NAME)*

“I UNDERSTAND THAT THIS ORGANIZATION HAS A COMMITMENT TO MAINTAIN AN ALCOHOL/ DRUG-FREE WORKPLACE AND UNLESS PROHIBITED BY STATE LAW, REQUIRES A DRUG SCREENING TEST AS A PART OF ITS SELECTION AND HIRING PROCESS. I UNDERSTAND THAT SUCH DRUG SCREENING WILL CONSIST OF THE TESTING OF A URINE SAMPLE OR OTHER MEDICALLY RECOGNIZED DEVICES DESIGNED TO DETECT TRACEABLE AMOUNTS OF A CONTROLLED SUBSTANCE IN MY BODY. IF AFTER A SECOND CONFIRMATORY TEST, IT IS DETERMINED MY SPECIMEN CONTAINS A CONTROLLED SUBSTANCE OR WAS ADULTERED OR SUBSTITUTED, I WILL BE DISQUALIFIED FROM CONSIDERATION FOR EMPLOYMENT AND ANY OFFER OF EMPLOYMENT WILL BE WITHDRAWN. I FURTHER UNDERSTAND AND AGREE THAT IF I AM EMPLOYED, I MAY BE REQUIRED TO SUBMIT TO ALCOHOL/DRUG-TESTING UNDER CERTAIN CIRCUMSTANCES DURING MY EMPLOYMENT. I HAVE READ, UNDERSTAND, AND AGREE TO THIS STATEMENT” - (TYPE FULL NAME)*